Basic Information
| Provider Information | |||||||||
| NPI: | 1780655340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITNEY | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1327 TROUP HWY | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757014443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035314733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | G0285 | TX | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 123448604 | 05 | TX | MEDICAID | 8BC079 | 01 | TX | BCBS OF TEXAS | OTHER | 123448605 | 05 | TX | MEDICAID | TIN PLUS 021 | 01 | TX | TRICARE | OTHER |